Performance health administration and the return of the French second empire

DOIhttp://doi.org/10.1002/pa.1686
Date01 May 2018
Published date01 May 2018
ACADEMIC PAPER
Performance health administration and the return of the French
second empire
Daniel Simonet
School of Business and Administration,
American University of Sharjah, Sharjah,
United Arab Emirates
Correspondence
Daniel Simonet, American University of
Sharjah, School of Business and
Administration, PO Box 26666, Sharjah,
United Arab Emirates.
Email: dsimonet@aus.edu
In the French health care system, costcontainment strategies have become the new priority.
Novel instrumental values (e.g., benchmarking, incentivization or premiums, and Diagnostic
Related Groups) and reforms of the hospital governance via the 2009 HPST Act served an auster-
ity agenda at the expense of more patientcentered approaches (e.g., patient choice and case
management). Effecting actual changes proved more difficult than collecting data on the health
system. Decisionmaking powers are increasingly concentrated within the welfare elite at the
expense of the medical profession. Hence, a return to the earlier French tradition of Jacobinism.
Transparency has yet to be achieved.
1|INTRODUCTION
French top political circles adopted New Public Management (NPM) to
satisfy EU requirements for stricter budget discipline rather than meet
user demand for greater responsiveness. Did these NPMmodeled
reforms led to an idiosyncratic restructuring of the French health sys-
tem? Could it be at the expense of public participation? French NPM
paved the way for a recentralization of policy decisions and a
verticalization of the chain of command that contrast with Anglo
Saxon deamalgamation and devolution strategies. With the exception
of the 2009 HPST law, French health authorities did not adopt sweep-
ing reforms, preferring tools that were less visible to the public such as
novel accounting mechanisms and a reform of the hospital governance.
Who were the main reform beneficiaries? In retrospect, it appears that
the French welfare elite was able to capitalize on reforms to
strengthen its prerogatives. Hence, a consolidation of the center at
the expense of the medical profession and the public. Can we take
stock of these reforms? Though the emergence of health economics
as a fullfledged academic discipline in the 1990s2000s turned
evidencedbased policies into a crucial factor in decisionmaking,
evaluation of reforms remains challenging for public administration
scientists. Authorities continue to face difficulty in interpreting and
using evidence to orient health policies.
1.1 |The rise of evidencedbased policies
Traditionally, the national target for health insurance expenditures
known as the ONDAM (Objectif National des Dépenses d'Assurance
Maladie) is divided into four main categories, each having their own
cap: ambulatory care (GPs, specialists, nurses, drugs, etc.), public hospi-
tals, private hospitals, and health services for the handicapped and
elderly. It is approved annually by the parliament under the Social
Security Funding Act (or Loi de Financement de la Sécurité sociale).
This approval, however, is purely indicative because all deficits will
eventually be covered by the government. Hence, a culture of deficit.
The deficit of public hospitals reached 400 million in 2013. The cumu-
lative shortfall stood at 30 billion or 1.4% of gross domestic product
(GDP). In 2012, however, it artificially declined due to deferrals ranging
from 455 to 150 million. Though easy to implement, acrosstheboard
cuts are no longer adequate. More evidencebased policies are needed
to tackle government deficits and debt accumulation. Spending
reviews and smart cutsthat is, cuts supported by evidence (Van
Nispen, 2016) are now at the forefront of French health policies. In this
aim, policymakers advocated the use of Health Information Systems
such as the patient electronic medical records, imposed a mandatory
medical information unit in every hospital, and a patient discharge
summary to quantify outputs. These will be instrumental in the formu-
lation of evidencedbased policies (Cucciniello, Lapsley, & Nasi, 2016).
Public administrators are also pressed to emphasize outcomesbased
reimbursement rather than activitybased costing (e.g., Diagnostic
Related Groups [DRGs] and T2A) and to set priorities based on effi-
ciency rules (Angelis, Tordrup, & Kanavos, 2017) rather than effective-
ness alone to ensure longterm sustainability of the health system.
Evidencedbased policy was preferred over other more sweeping,
and often divisive, reforms such as hospital mergers that became pop-
ular overseas (as exemplified by the creation of nationwide hospital
networks in the United States in the late 1990s) but proved disap-
pointing in France. Despite specific funding for mergers, these were
Received: 15 September 2017 Accepted: 6 October 2017
DOI: 10.1002/pa.1686
J Public Affairs. 2018;18:e1686.
https://doi.org/10.1002/pa.1686
Copyright © 2017 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pa 1of8

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